›First 5 minutes
›Cardiac monitor
›Two large bore IV lines if toxic appearance
›Oxygen if saturation under 92 percent
›IV fluids if hypotension or poor perfusion
›Diagnostic sequencing
›Arthrocentesis prioritized before antibiotics when stable
›Blood cultures before antibiotics when febrile or toxic
›Imaging for effusion localization when uncertain anatomy
›Empiric antibiotics
›Timing
›If septic shock then antibiotics immediately after cultures
›If stable then antibiotics after synovial fluid obtained
›Typical adult empiric coverage
›Vancomycin IV
›Initial dose 15 to 20 mg per kg
›Trough or AUC monitoring local protocol dependent
›Ceftriaxone IV
›2 g daily
›Gram negative risk or immunocompromised
›Cefepime IV
›2 g every 8 to 12 hours renal adjustment required
›Piperacillin tazobactam IV
›4.5 g every 6 to 8 hours renal adjustment required
›Gonococcal concern
›Ceftriaxone IV or IM
›1 g daily
›Doxycycline PO
›100 mg twice daily for 7 days when chlamydia not excluded
›Beta lactam anaphylaxis
›Vancomycin IV
›Aztreonam IV
›2 g every 8 hours renal adjustment required
Source control and consultation
›Source control and consultation
›Orthopedics consultation
›Suspected septic arthritis
›Prosthetic joint
›Infectious diseases consultation
›Bacteremia
›Unusual pathogens
›Operative washout triggers
›Hip involvement
›Shoulder involvement
›Failure of serial aspirations
Analgesia and supportive care
›Analgesia and supportive care
›Acetaminophen PO or IV
›1000 mg every 6 to 8 hours
›Maximum 3000 mg per day in many adults
›NSAID when appropriate
›Ibuprofen PO
›400 mg every 6 to 8 hours
›Contraindications
›CKD
›GI bleeding risk
›Opioid for severe pain
›Morphine IV
›0.05 mg per kg
›Repeat every 10 to 15 minutes to effect
›Reassessment loop
›Vitals every 30 to 60 minutes if ill appearing
›Pain and range of motion trend
›Perfusion and mental status trend
›Culture and Gram stain updates